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MODEL OF PAYMENT AND APPOINTMENT SHEET

financial

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DOCUMENTE SIMILARE

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IMPACT, DVANTAGES & DISADVANTAGES OF BLACK MONEY

Date : 02.05.08

Dear MR. Tiberiu STAN;

Thank you for selecting Anadolu Medical Center for your healthcare needs.I will be pleased to assist you during your visit to The Anadolu Medical Center to ensure that you receive the highest level of service at all times.You requested appointments have been scheduled and are detailed on attached form.Outlined below are a few notes about your pending visit.

Appointment Confirmation Information

  1. Our office can assist with transportation and lodging arrangements.We have negotiated special rates for patients of The Anadolu Medical Center.Please let us know ahead of time how can assist you.
  2. The attached Credit Card Authorization and Business Authorization Notice forms should be returned to our office in orfder to confirm the appointment(s).These forms must be received within 2 business days of the appointment date or 7 business days prior to a surgery or admission date,or the appointment will have to be canceled.
  3. Bring copies of your passport, medical records and any applicable films to the appointment.
  4. Please arrive to the International Services of Anadolu Medical Center 1 hour prior to your appointment time to complete the registration process,unless instructed otherwise. Anadolu Medical Center , International Services Department Phone :+9 0262 678 55 13
  5. Notice of appointment cancellations must be provided at least 2 days prior to an appointment date or 7 days prior to a surgery or admission date.

Finance

  1. All payments for medical services are expected before or on the first appointment date for self pay patients.You may either pay with a credit card,money order or bank wire the funds.Directions on how to deposit funds are attached to this letter. During the treatment, care or recovery process, the final state of the bill will be checked within weekly intervals to verify if any extra payments are needed beyond the estimations given and the payments needed will be collected according to this verification..
  2. For patients possessing International insurance,please contact your International coordinator to verify benefit eligibility and authorization for the visit when you receive this letter.
  3. Any balance or credit remaining on your account after departure will be debited or credited backto the credit card number on file.
  4. All deposits are based on an estimate only and we will be able to inform you of the final charges when the final bill is generated Ė approximately 2-3 months after the last appointment date.
  5. If the patient and relatives do not speak English, the interpreter demand (as daily translation or on-call translation) must be made by the patient/patientís family/legal represantative of the patient to the International Services Department and the daily charges will be reflected to the invoice .
  6. The responsability of payment of the patientís transfer to another location by air travel or land ambulance in case of any need during or after the treatment process must be considered in advance and taken in charge by the patient/legal represantative of the patient.

If you have any other questions, please donít hesitate to contact me.

Murat Ercan

International Services Department Specialist

††††††††††††††††††††††††††††††††††††††††††††††

††††††††††† ††††††††††† †††† Appointment Itinerary & Estimated Cost

Date

Time

Visit Type

Department

Provider

Treatment

Estimated Cost

Outpatient

Urology

Prof. Dr. Nazmi Yalcin İlker Ė Dr. Aslan Demir

Urology Normal Examination

167 Ytl

85 Ä (by todayís currency)

Outpatient

Radiology

Radiology Department

Urinary SystemCt

850 Ytl (+200Ytl if injection needed)

440 Ä (by todayís currency)

Outpatient

Radiology

Nuclear Medicine Department

Pet-Ct Scan

2.683 Ytl

1.360 Ä (by todayís currency)

Outpatient

Radiation Oncology

Prof. Dr. Kayihan Engin

Radiation Oncology Normal Examination

167 Ytl

85 Ä (by todayís currency)

Signature:

  • The need for further tests /appointment and the definitive course of treatment will be evaluated during this appointment.
  • The above referenced costs are ESTIMATES for the consultation/ test listed and are intended only as a guide to assist you in preplanning your visit.The actual final charges may vary from initial estimated amount.
  • These cost estimations do not cover any price changes due to any complications.
  • Package prices exclude pathology, attendance and special material costs.
  • Prices presented above as in currencies other than YTL (Turkish Lira) might vary according to the daily changing exchange rates.

With the document hereby, I, ,certify that I perfectly understand Anadolu Medical Center International Patient Services treatment planning and services policy and guarantee to make my payments according to Anadolu Medical Center payment procedure.

Last Name Ė First Name:†††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††† Signature:

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

INTERNATIONAL SERVICES

CREDIT CARD AUTHORIZATION FORM

††††††††††††††††††††††† †††††††††††††††† (The following information is strictly confidential )

I authorize The Anadolu Medical Center to charge my credit card in event of the following :

         If an open balance exists on my account after final charges have been posted for medical services provided (This may occur because all up-front payments collected are based on estimates only which may vary from actual final charges.)

         FOR PATIENTS POSSESSING PRIVATE INSURANCE : I acknowledge financial responsibility for any health insurance deductibles, co-insurance, or failure of any insurance carrier to pay the hospital or physicianís charges in full when rendered.Anadolu Medical Center may not participate with many insurance provider panels; in these situations insurance companies may reimburse the patient or subscriber directly.

I acknowledge any deposit I make is based on Cost Estimate ONLY and Actual Charges will vary from the cost estimate.I acknowledge responsibility for any balance due between the Cost Estimate and the Actual Charges.

ź         American Express††††††††††††††††††††††††††† ź†††† MasterCard††††††††††††††††††††††† ††††††††††† źVisa

Credit Card Number____________________________________†† 3/4 Digit s___________
Expiration Date______/______
Card Holder

Name________________________________________________________________

Card Holder Signature______________________________________________________________

Patient Name__________________________________________________________________†††††††

†† ††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

PLEASE COMPLETE THE INFORMATION REQUESTED ABOVE AND FORWARD TO :

Anadolu Sağlık Merkezi

Attn : Murat Ercan

Anadolu Caddesi No:1 Bayramoğlu «ıkısı

«ayırova Mevkii,Gebze 41400 Kocaeli /Turkey

Tel: +90 262 678 55 13

Fax:+90 262 654 00 53

E-mail : murat.ercan@anadolusaglik.org

††††††††††††††††††††††††††††††††††††††††††††††††††††††††††

For your convenience, please note that Anadolu Medical Center accepts the following methods of payment: Visa, Master Card and Cash at the time of service. Should you prefer to wire transfer initial deposits to secure scheduled appointments, or, for the cost of schedule procedures to funds to Anadolu Medical Center, please do so as follows

BANK ACCOUNTS

Anadolu Eğitim Sosyal Yardım Vakfı Sağlık Tesisleri İktisadi İsletmesi

AlternatifBank A.S.

SWİFT CODE : ALFBTRIS

A-BANK Anadolu Sağlık Merkezi Subesi 9400-01407470 TL IBAN : TR150012409400TRY001407470

A-BANK Anadolu Sağlık Merkezi Subesi 9400-01411961 $ IBAN : TR250012409400USD001411961

A-BANK Anadolu Sağlık Merkezi Subesi 9400-01411962 Ä IBAN : TR490012409400EUR001411962

It is essential that you note the patientís name and history number as reference on this wire transfer.Also, please fax a copy of your wire confirmation to:

International Services

Please feel free to contact the International Services at +90 262 678 55 13 if you have any further questions or inquiries.Thank you for choosing Anadolu Medical Center for your health care needs.

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